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What Are the Transparency Requirements for Handling Requests for Provider Directory Information?

EBIA  

EBIA  

QUESTION: We’ve heard that our group health plan will be subject to provider directory transparency disclosures that require protocols for responding to individual requests for directory information. What are the requirements, and when do they take effect?

ANSWER: As we discussed in a previous Checkpoint Question of the Week, a number of transparency requirements impacting provider directories go into effect for plan years beginning in 2022. For instance, a group health plan is required to establish a database on its public website that contains directory information for each provider and facility with which it has a direct or indirect contractual relationship for furnishing items and services. A plan must also establish a process to verify and update the information included in the database, and, as you point out, must establish a protocol to respond to individual requests about directory information.

More specifically, a plan must establish a protocol for responding to a request from an individual enrolled in the plan about whether a health care provider or facility has a contractual relationship to furnish items or services under the plan. The protocol must meet specified requirements. For instance, when an individual’s request is made by telephone, a response must be provided as soon as practicable and in no case later than one business day after the call is received and must be provided through either written electronic communication or print communication, as requested by the individual. Any such communication must be retained in a file maintained by the plan for at least two years following the response. Furthermore, in certain instances when an individual obtains items or services from a nonparticipating (out-of-network) provider after receiving incorrect information from the plan that the provider is a participating (in-network) provider, a plan is required to (1) limit cost-sharing for those items and services to an amount that is no greater than the cost-sharing that would apply under the plan for items or services furnished by a participating provider; and (2) apply the deductible or out-of-pocket maximum (if any) that would apply if the items or services were furnished by a participating provider.

Although the transparency requirements for provider directories apply to plan years beginning on or after January 1, 2022, the agencies have advised that they will not issue rules until after the effective date. Nevertheless, plans are expected to implement these provisions using a good faith, reasonable interpretation of the statute. In the meantime, the agencies have advised that they will not deem plans to be out of compliance if, when an individual is inaccurately informed that a nonparticipating provider or facility is a participating provider or facility, the plan or insurer (1) imposes a cost-sharing amount that is not greater than the cost-sharing amount for a participating provider, and (2) counts those cost-sharing amounts toward any deductible or out-of-pocket maximum.

For more information, see EBIA’s Health Care Reform manual at Section XXXVII.E.4 (“Provider Directory Disclosures”). See also EBIA’s Self-Insured Health Plans manual at Section XXVIII.I (“Surprise Medical Billing Transparency Disclosures”).

Contributing Editors: EBIA Staff.

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